To make a referral to our 6 week online counselling service, please fill in the fields below.

We are committed to protecting your privacy and keeping the information you provide confidential. Your information will not be used for any other purpose and is managed according to the General Data Protection Regulation (GDPR) and the Data Protection Act 2018. You can find more information regarding our privacy policy on our website www.londonfriend.org.uk/2012/privacy

First Name
Last Name
Date of Birth
Mobile Number
Ok to Voice Mail?
Email Address
Ok to Email?
Address
Gender
Is your current gender different than to that assigned at birth?
Are you Intersex?
Sexuality
Employment Status
Nationality
Ethnicity
Religion/Faith
Disability/Access Requirements/Communication Needs
If yes, please give details:
How did you hear about London Friend?
Have you accessed London Friend previously?
If yes, which service:
Do you know anyone privately at London Friend?
If yes, who:
Assessment Availability
Please be as specific as you can regarding days and times. The more availability you give us, the easier and quicker it will be to book you in.
Reasons for Counselling
Please give general topics or themes you would like to discuss with a counsellor.

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